Papel de la yeyunoplastia en la reconstrucción esofágica compleja / Role of jejunoplasty in complex esophageal reconstruction

Introducción: La reconstrucción esofágica es un proceso quirúrgico técnicamente muy complejo, gravado por una importante morbilidad. Clásicamente se han utilizado la gastroplastia y la coloplastia, aunque la yeyunoplastia ya fue descrita por Roux en 1907. Parece demostrado que la plastia de yeyuno libre es una muy buena opción en el tratamiento de la enfermedad del esófago cervical, pero no está tan claro el papel de la yeyunoplastia supercharged en la reconstrucción del esófago torácico. El objetivo de este estudio es el análisis de las reconstrucciones esofágicas realizadas en nuestra unidad y que precisaron de un injerto de yeyuno. Métodos: Estudio retrospectivo de las reconstrucciones esofágicas realizadas con yeyunoplastias en nuestra unidad entre enero de 2011 y diciembre de 2019. Se analizan datos epidemiológicos, indicaciones, técnica quirúrgica y morbimortalidad. Resultados: Se realizaron 67 procedimientos quirúrgicos de reconstrucción esofágica compleja de los que 10 fueron yeyunoplastias: 5 yeyunos libres en esófago cervical y 5 supercharged en esófago torácico con abordaje transesternal. La morbilidad, mortalidad, estancia media y tiempo de retirada de la alimentación enteral fueron menores en los yeyunos libres que en los supercharged. Conclusiones: En nuestro grupo la yeyunoplastia supercharged es la última opción para la reconstrucción del esófago torácico; el acceso por esternotomía media nos permite un excelente abordaje del mediastino anterior y los vasos mamarios internos. El yeyuno libre sería la primera elección —con indemnidad del resto de esófago— en la reconstrucción del esófago cervical. (AU)

Introduction: Esophageal reconstruction is a very complex surgical procedure, burdened by significant morbidity. Gastroplasty and coloplasty have classically been used. Free jejunal plasty has shown to be a very good option in the treatment of cervical esophagus pathology, but the role of supercharged jejunoplasty in thoracic esophagus reconstruction is still controversial. Methods: A retrospective study of esophageal reconstructions with jejunoplasties performed in our unit between January 2011 and December 2019. Epidemiological data, indications, surgical technique, and morbidity and mortality were analyzed. Results: 67 procedures of esophageal reconstruction were performed, 10 of which were jejunoplasties: 5 free jejunums and 5 supercharged. Morbidity, mortality, mean stay and withdrawal time from enteral feeding were lower in free than in supercharged jejunums. Conclusions: Supercharged jejunoplasty was the last option for reconstruction of the thoracic esophagus. Median sternotomy access provides an excellent approach to the anterior mediastinum and the internal mammary vessels. The free jejunum would be the first choice, with the indemnity of the rest of the esophagus, in the reconstruction of the cervical esophagus. (AU)

A pilot randomized controlled trial on the utility of gastric conditioning in the prevention of esophagogastric anastomotic leak after Ivor Lewis esophagectomy. The APIL_2013 Trial.

BACKGROUND: Anastomotic leakage (AL) after Ivor Lewis esophagectomy is associated with high morbidity and mortality. Preoperative gastric conditioning (GC) improves blood perfusion of the gastroplasty, one of the most important factors for anastomotic viability. This pilot randomized controlled trial aimed to evaluate the feasibility of GC before oesophageal surgery in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer, who required an Ivor Lewis esophagectomy. MATERIALS AND METHODS: This was a randomized (1:1), open-label, single-centre, controlled, parallel-group, pilot clinical trial. Two study groups: 1) GC-group: patients who underwent an Ivor Lewis esophagectomy and GC before surgery; 2) Surgery alone (SA)-group: patients who underwent only Ivor Lewis esophagectomy. Feasibility was assessed by means of the number of patients in whom a GC was performed, and the cumulative incidence of postoperative AL. Secondary endpoints were conduit necrosis (CN), hospital stay, morbidity, mortality, and anastomotic stricture. RESULTS: Between 2015 and 2018, 38 patients were randomized and analysed: 20 to GC-group and 18 to SA-group. 17 GCs (85%) were successfully performed, right gastric artery occlusion failed in three patients. Morbidity after GC occurred in 5/22 patients (all Clavien-Dindo ≤ IIIa). The cumulative incidence of AL was 15.0% (3/20, 95%CI: 5.2-36.0%) in GC-group and 33.3% (6/18, 95%CI: 16.3-56.3%) in SA-group, p-value: 0.184. CN: 0/20 vs. 1/18 (p-value: 0.474); surgical morbidity (Clavien-Dindo III-V): 7/20 vs. 12/18 (p-value: 0.070); hospital stay (median [range] days): 12 [9-45] vs. 27.5 [10-166] (p-value: 0.067). When only successful GCs (three arteries) were included for analysis, ischemia-related gastric conduit failure (AL and CN) was lower in the GC group (p-value: 0.041). CONCLUSIONS: Preoperative arteriographic GC before Ivor Lewis esophagectomy is a feasible and safe procedure and seems it may reduce AL in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer.

Role of jejunoplasty in complex esophageal reconstruction.

INTRODUCTION: Esophageal reconstruction is a very complex surgical procedure, burdened by significant morbidity. Gastroplasty and coloplasty have classically been used. Free jejunal plasty has shown to be a very good option in the treatment of cervical esophagus pathology, but the role of supercharged jejunoplasty in thoracic esophagus reconstruction is still controversial. METHODS: A retrospective study of esophageal reconstructions with jejunoplasties performed in our unit between January 2011 and December 2019. Epidemiological data, indications, surgical technique, and morbidity and mortality were analyzed. RESULTS: 67 procedures of esophageal reconstruction were performed, 10 of which were jejunoplasties: 5 free jejunums and 5 supercharged. Morbidity, mortality, mean stay and withdrawal time from enteral feeding were lower in free than in supercharged jejunums. CONCLUSIONS: Supercharged jejunoplasty was the last option for reconstruction of the thoracic esophagus. Median sternotomy access provides an excellent approach to the anterior mediastinum and the internal mammary vessels. The free jejunum would be the first choice, with the indemnity of the rest of the esophagus, in the reconstruction of the cervical esophagus.

Ischemic Conditioning in the Right Colon and Terminal Ileum: An Experimental Rat Model.

INTRODUCTION: Preoperative gastric ischemic conditioning (IC) improves the outcome of esophageal replacement gastroplasty and is associated with low morbidity. However, when the stomach cannot be used for esophageal replacement, a colonic replacement is required. The study aim was to assess the viability of right colon and terminal ileum IC in a rat model and the histological damage/recovery sequence and determine if neovascularization is a potential adaptive mechanism. METHODS: The study was conducted in Rattus norvegicus with ileocolic vascular ligation. Seven groups of animals were established (6 rats per group) with groups defined by the date of their post-IC euthanasia (+1, +3, +6, +10, +15, and +21 days). Comparisons were made with a sham group. Viability of the model was defined as <10% of transmural necrosis. The evaluation of histological damage used the Chiu score in hematoxylin and eosin sections of paraffin-embedded specimens with CD31 immunohistochemical assessment of neovascularization by the median of submucosal vessel counts in 5 high-magnification fields. RESULTS: Transmural colon necrosis occurred in 1/36 animals (2.78%) with no animal demonstrating transmural ileal necrosis. The maximum damage was observed in the colon on +1 day post-IC (average Chiu score 1.67, p = 0.015), whereas in the ileum, it was on days +1, +3, and +6 (average Chiu score 1.5, 1.3, and 1.17; p = 0.015, 0.002, and 0.015, respectively). In the +21-day group, histological recovery was complete in the colon in 4 (66.7%) of the 6 animals and in the ileum in 5 (83.3%) of 6 animals. There were no significant differences in quantitative neovascularization in any of the groups when compared with the sham group or when comparisons were made between groups. CONCLUSIONS: The tested animal model for IC of the colon and terminal ileum appeared to be feasible. Histological damage was maximal between the 1st and 3rd day following IC, but by day 21, recovery was complete in two-thirds of the rats. There was no evidence in this preliminary IC model that would suggest neovascularization as an adaptive mechanism.

Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis.

BACKGROUND: The concept of textbook outcome (TO) has been proposed for analyzing quality of surgical care. This study assessed the incidence of TO among patients undergoing curative gastric cancer resection, predictors for TO achievement, and the association of TO with survival. METHOD: All patients with gastric and gastroesophageal junction cancers undergoing curative gastrectomy between January 2014-December 2017 were identified from a population-based database (Spanish EURECCA Registry). TO included: macroscopically complete resection at the time of operation, R0 resection, ≥15 lymph nodes removed and examined, no serious postoperative complications (Clavien-Dindo ≥II), no re-intervention, hospital stay ≤14 days, no 30-day readmissions and no 90-day mortality. Logistic regression was used to assess the adjusted achievement of TO. Cox survival regression was used to compare conditional adjusted survival across groups. RESULTS: In total, 1293 patients were included, and TO was achieved in 541 patients (41.1%). Among the criteria, "macroscopically complete resection" had the highest compliance (96.5%) while "no serious complications" had the lowest compliance (63.7%). Age (OR 0.53 for the 65-74 years and OR 0.34 for the ≥75 years age group), Charlson comorbidity index ≥3 (OR 0.53, 95%CI 0.34-0.82), neoadjuvant chemoradiotherapy (OR 0.24, 95%CI 0.08-0.70), multivisceral resection (OR 0.55, 95%CI 0.33-0.91), and surgery performed in a community hospital (OR 0.65, CI95% 0.46-0.91) were independently associated with not achieving TO. TO was independently associated with conditional survival (HR 0.67, 95%CI 0.55-0.83). CONCLUSION: TO was achieved in 41.1% of patients who underwent gastric cancer resection with curative intent and was associated with longer survival.

Linfografía y embolización del conducto torácico como tratamiento del quilotórax tras esofagectomía por cáncer de esófago / Lymphography and embolization of the thoracic duct as a treatment for chylothorax after esophagectomy for esophageal cancer

Introducción: El quilotórax es una complicación poco frecuente en las esofagectomías pero que se asocia a un aumento de la mortalidad posquirúrgica. Se han descrito diversos factores que pueden incrementar su aparición y el tratamiento del mismo es controvertido, siendo la linfografía con embolización percutánea del conducto torácico uno de los usados por varios grupos. Material y método: Estudio retrospectivo de los pacientes a los que se les realizó una esofagectomía por cáncer de esófago o de la unión esofagogástrica a Siewert I/II entre enero del 2010 y abril del 2019, y desarrollaron un quilotórax como complicación. Se analizan datos epidemiológicos, el tipo de cirugía, la morbilidad y el tratamiento. Resultados: Se realizaron 274 esofagectomías por cáncer en el período comprendido. Trece pacientes (4,7%) fueron diagnosticados de quilotórax en el postoperatorio; 3 se resolvieron con tratamiento conservador. En los 10 pacientes restantes se realizó linfografía con punción de la cisterna de Pécquet y embolización del conducto torácico, con resolución del quilotórax en 9. Un paciente (10%) presentó una fístula biliar después del procedimiento. Conclusiones: La linfografía con punción de la cisterna de Pécquet y embolización del conducto torácico es una técnica con baja morbilidad y buenos resultados en la resolución del quilotórax postesofagectomía. (AU)

Introduction: Chylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups. Material and method: Our retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed. Results: 274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure. Conclusions: Lymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy. (AU)

Lymphography and embolization of the thoracic duct as a treatment for chylothorax after esophagectomy for esophageal cancer. / Linfografía y embolización del conducto torácico como tratamiento del quilotórax tras esofagectomía por cáncer de esófago.

INTRODUCTION: Chylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups. MATERIAL AND METHOD: Our retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed. RESULTS: 274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure. CONCLUSIONS: Lymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy.

Does gastric conditioning decrease the incidence of cervical oesophagogastric anastomotic leakage? / ¿Puede el acondicionamiento gástrico disminuir la incidencia de dehiscencia anastomótica esofagogástrica cervical?

INTRODUCTION: Oesophageal reconstruction by gastroplasty with cervical anastomosis has a higher incidence of dehiscence. The aim of the study is to analyse the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning of the gastric conduit. METHODS: Prospective analysis of patients who underwent gastric conditioning two weeks prior to oesophageal reconstruction, from January 2001 to January 2014. The conditioning was performed by angiographic embolization of the left and right gastric artery, and splenic artery. The main variable analysed was the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis. Secondary variables analysed were the result of the conditioning, complications arising from that procedure and in the postoperative period, and mean length of postconditioning and postoperative hospital stay. RESULTS: Gastric conditioning was indicated in 97 patients, with neoplasia being the most frequent aetiology motivating the oesophageal reconstruction (76%). 96 procedures were successfully carried out, arterial embolization was complete in 80 (83%). The morbidity rate was 13%, with no mortality. Postoperative morbidity was 45%; the most frequent complications associated with the surgery were respiratory problems. Six (7%) patients experienced cervical fistula, and all received conservative treatment. The rate of postoperative mortality was 7%. CONCLUSIONS: In our serie the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning is 7%. Angiographic ischaemic conditioning is a procedure with acceptable morbidity.

¿Puede el acondicionamiento gástrico disminuir la incidencia de dehiscencia anastomótica esofagogástrica cervical? / Does gastric conditioning decrease the incidence of cervical oesophagogastric anastomotic leakage?

Introducción: La reconstrucción esofágica mediante gastroplastia con anastomosis cervical es una técnica una mayor dehiscencia anastomótica remarcable.. El objetivo de este estudio es analizar la incidencia de dehiscencia anastomótica en pacientes sometidos a gastroplastia con anastomosis cervical tras acondicionamiento isquémico angiográfico del tubo gástrico. Métodos: Análisis prospectivo de pacientes que se sometieron a acondicionamiento gástrico 2 semanas antes de la reconstrucción esofágica, desde enero de 2001 hasta enero de 2014. El acondicionamiento se realizó mediante embolización angiográfica de las arterias gástricas izquierda y derecha, y la arteria esplénica. La variable principal analizada fue la incidencia de dehiscencia anastomótica en pacientes sometidos a gastroplastia con anastomosis cervical. Las variables secundarias analizadas fueron el éxito del acondicionamiento, las complicaciones tras este procedimiento y postoperatorias, y la duración media de la estancia hospitalaria postacondicionamiento. Resultados: El acondicionamiento gástrico se indicó en 97 pacientes, siendo la neoplasia la etiología más frecuente que motivó la reconstrucción esofágica (76%). Se realizaron 96 procedimientos con éxito, la embolización arterial fue completa en 80 (83%). La morbilidad fue del 13%, sin mortalidad. La morbilidad postoperatoria fue del 45%; las complicaciones más frecuentes asociadas a la cirugía fueron los respiratorios. Seis (7%) pacientes presentaron fístula cervical y todos tratados de forma conservadora. La mortalidad postoperatoria fue del 7%. Conclusiones: En nuestra serie, la incidencia de dehiscencia anastomótica en pacientes sometidos a gastroplastia con anastomosis cervical tras acondicionamiento isquémico angiográfico es del 7%. El acondicionamiento isquémico angiográfico es un procedimiento con una morbilidad aceptable (AU)

Introduction: Oesophageal reconstruction by gastroplasty with cervical anastomosis has a higher incidence of dehiscence. The aim of the study is to analyse the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning of the gastric conduit. Methods: Prospective analysis of patients who underwent gastric conditioning two weeks prior to oesophageal reconstruction, from January 2001 to January 2014. The conditioning was performed by angiographic embolization of the left and right gastric artery, and splenic artery. The main variable analysed was the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis. Secondary variables analysed were the result of the conditioning, complications arising from that procedure and in the postoperative period, and mean length of postconditioning and postoperative hospital stay. Results: Gastric conditioning was indicated in 97 patients, with neoplasia being the most frequent aetiology motivating the oesophageal reconstruction (76%). 96 procedures were successfully carried out, arterial embolization was complete in 80 (83%). The morbidity rate was 13%, with no mortality. Postoperative morbidity was 45%; the most frequent complications associated with the surgery were respiratory problems. Six (7%) patients experienced cervical fistula, and all received conservative treatment. The rate of postoperative mortality was 7%. Conclusions: In our serie the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning is 7%. Angiographic ischaemic conditioning is a procedure with acceptable morbidity (AU)

Factors influencing mortality in patients undergoing surgery for acute pancreatitis: importance of peripancreatic tissue and fluid infection.

OBJECTIVES: The aims of present study were to analyze the mortality risk factors in patients who had surgery for acute pancreatitis and to assess the importance of culturing peripancreatic tissue or fluid infection to ascertain the infection status. METHODS: Surgery was indicated both in patients with infected severe acute pancreatitis and in those with sterile pancreatitis with an unfavorable course. During surgery, cultures were taken of tissues (pancreatic necrosis and peripancreatic fat), intra-abdominal fluid, and bile. RESULTS: Of 107 patients operated on, fluid culture was analyzed in 94 patients, pancreatic necrosis in 61 patients, peripancreatic fat in 39 patients, and bile in 38 patients. Sterile pancreatitis with sterile ascites was found in 17 patients, sterile pancreatitis with infected ascites in 22, and pancreatic tissue infection in 60. Multivariate analysis demonstrated that sterile tissue cultures, age over 65 years, and fewer than 12 days between the beginning of pain and surgery were risk factors for mortality. Sterile pancreatitis with sterile ascites and sterile pancreatitis with infected ascites had similar postoperative mortality (41% and 50%, respectively); the group with pancreatic tissue infection had a lower mortality (20%). CONCLUSIONS: Early surgery, advanced age, and sterility of tissue cultures have been demonstrated as mortality factors for acute pancreatitis. Intra-abdominal fluid may be infected in the presence of sterile necrosis.